Provider Demographics
NPI:1194170134
Name:STANFORD, KIM
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:
Last Name:STANFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 ALYENE DR
Mailing Address - Street 2:
Mailing Address - City:STILWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74960-3230
Mailing Address - Country:US
Mailing Address - Phone:918-575-2695
Mailing Address - Fax:
Practice Address - Street 1:716 S 2ND ST # 1014
Practice Address - Street 2:
Practice Address - City:STILWELL
Practice Address - State:OK
Practice Address - Zip Code:74960-4806
Practice Address - Country:US
Practice Address - Phone:919-696-6212
Practice Address - Fax:918-696-6213
Is Sole Proprietor?:No
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor